Benefit Summary for FOSTER DESIGN
Blue Choice Triple Option Comprehensive Major Medical Program
Effective November 1, 2010 – October 31, 2011
Grandfathered
Maximum benefits are available when services are received from Blue Choice providers. Your financial responsibility is based on
the provider network you select. Non-Blue Choice & Non-CAP: Difference between the payment allowance and provider charge,
additional 20% coinsurance amount, deductible, coinsurance or copay amount CAP (Non-Blue Choice): Additional 20%
coinsurance amount,* deductible, coinsurance or copay amount Blue Choice: Deductible, coinsurance or copay amount
*Limited to a combined $2,000 per person, $4,000 two-or-more persons each benefit period.
Member Pays
Triple Option
(Deductible per group anniversary benefit period)
Option 1
Option 2
Option 3
Coinsurance (Member portion for most services)
Annual Out-of-Pocket Maximum
(includes deductible/coinsurance)
Copays do not apply to the annual out-of-pocket
amount. At the group's anniversary, an employee can
upgrade no more than one deductible level within an
option per benefit period. An employee can
downgrade to any deductible level within an option
per benefit period.
$500/$1,000 individual/two-or-more persons
$1,000/$2,000 individual/two-or-more persons
$1,500/$3,000 individual/two-or-more persons
20% of allowed amounts after deductible has been met; up to
$1,000/$2,000 individual/two-or-more persons maximum
Option 1 $1,500/$3,000 individual/two-or-more persons
Option 2 $2,000/$4,000 individual/two-or-more persons
Option 3 $2,500/$5,000 individual/two-or-more persons
After the annual out-of-pocket amount has been reached (deductible/coinsurance)
eligible benefits will be paid at 100% of the allowed amount
for the remainder of the benefit period.
Unlimited Lifetime Benefit. Eligible children covered to age 26.
Covered Services
Medical Services
• Doctor Visits — home/office (including hearing and
eye exam)
• Surgery — inpatient and outpatient
• Maternity Care
• Well Child & Well Baby Office Visit
• Immunizations up to age 72 months
• Immunizations over 72 months
• Well Women — Annual Check Up
Office Visit
Mammogram
Pap Smear
• Routine Physicals — Annual Check Up
Office Visit
• Injections
• Outpatient Radiology and Lab Services
$25 office visit copay
Subject to deductible/coinsurance
Subject to deductible/coinsurance
$25 office visit copay
Covers 100% of maximum allowance
Covers 100% of maximum allowance
$25 office visit copay
Pays 100% of the allowable charge to a maximum of $300 per person each benefit
period, then subject to deductible/coinsurance*
$25 office visit copay
Covers 100% of maximum allowance
Pays 100% of allowable charges up to a combined maximum of $300 for each covered
person, each benefit period*
* Combined benefit period maximum.
Inpatient Hospital
Pre-admission certification required for all planned
inpatient admissions at 1-800-782-4437
Accidental Injury Services
Ambulance Services
MC284j GF 09/10
Subject to deductible/coinsurance
Pays 100% up to $1,000 per person each benefit period, then subject to
deductible/coinsurance
Subject to deductible/coinsurance
Covered Services
Outpatient Hospital
Subject to deductible/coinsurance
Emergency Room Services
$100 copay per incident, then subject to deductible/coinsurance
If admitted to the same hospital as an inpatient within 24 hours of initial visit, copay is
waived and benefits are provided subject to deductible/coinsurance.
Home Health Care/Hospice
Pays 100% of allowable charges for Home Health Care;
Hospice paid 100% with a $5,000 lifetime maximum.
Freestanding Outpatient Facilities
(Examples: surgery, renal dialysis)
Subject to deductible/coinsurance
Medical Equipment/Disposable Supplies
Subject to deductible/coinsurance
Short-term Therapies — Physical, Speech and
Occupational, Respiratory and Cardiac
Subject to deductible/coinsurance
Mental Illness & Substance Use Disorders
• Inpatient Services
Requires pre-admission certification
from New Directions Behavioral Health
at
1-800-952-5906
Subject to deductible/coinsurance
$25 office visit copay
• Outpatient Services
Prescription Drugs
The quantity per prescription shall be the greater of a 34-day supply or 100 unit dosage, if
defined as a maintenance drug
• BlueRx Card - Retail
Generic/brand formulary/brand non-formulary
Diabetic Supplies are covered
• BlueRx Mail (90-day supply)
$15/$30/$45 copay
$37.50/$75/$112.50 copay
(Note: prior authorization and quantity limits may apply)
Premiums are based on an effective date of November 1, 2010 with census and contract counts of 12 Employee, 2 Emp/Child(ren), 4
Emp/Spouse, 4 Emp/Dependents and 0 MER. BCBSKS reserves the right to adjust premiums accordingly should enrollment vary from the
census.
Exclusions: The following procedures and all related services and supplies are not covered under this program. Services provided directly for or
relative to diseases or injuries caused by or arising out of acts of war, insurrection, rebellion, armed invasion, or aggression; duplicate benefits
provided under federal, state or local laws, regulations or programs, except Medicaid; cosmetic or reconstructive surgery (except as stated in the
certificate); any keratotomy procedures; charges for personal items; convalescent or custodial/maintenance care or rest cures; blood or payments
to donors of blood; any service or supply related to the medical management of obesity; charges for services by immediate relatives or by
members of your household; acupuncture and admissions for acupuncture; services related to temporomandibular joint dysfunction syndrome
over the amount specified in the certificate; services or supplies related to sex changes, sexual dysfunctions or inadequacies; any medically-aided
insemination procedure; services related to the reversal of sterilization procedures; mental illness or substance use disorder services provided by a
non-eligible provider; hearing aids; eyeglasses or contact lenses (except after the removal of cataracts); unnecessary services and admissions;
services or supplies which are experimental or investigative in nature; services not specifically listed as benefits in the certificate; services covered
and payable by any medical expense payment provision of any automobile insurance policy.
This is a brief summary of the coverage available under this program. It is not a legal document.
The exact provisions of the benefits and exclusions are con tained in the certificate.